YAYASAN KEPERAWATAN YOGYAKARTA

AKADEMI KEPERAWATAN YKY

YOGYAKARTA
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FORMAT PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS

PERIODE ANTENATAL

Hari/Tanggal :
Jam :
Tempat :
Oleh :
Sumber data :
Metode :

A. PENGKAJIAN
1. Identitas
a. Pasien
1) Nama Pasien :…………………………………………………
2) Tempat Tgl Lahir : ………………………………………………...
3) Agama : ………………………………………………..
4) Pendidikan : ………………………………………………..
5) Pekerjaan : ………………………………………………...
6) Status Perkawinan : ………………………………………………...
7) Suku / Bangsa : ………………………………………………..
8) Alamat : ………………………………………………...
9) Diagnosa Medis : ………………………………………………...
10) No. RM : ………………………………………………..
11) Tanggal Masuk RS : ………………………………………………..
a. Penanggung Jawab / Keluarga
1) Nama : ………………………………………………...
2) Umur : ………………………………………………...
3) Pendidikan : ………………………………………………..
4) Pekerjaan : ………………………………………………..
5) Alamat : ………………………………………………..
6) Hubungan dengan pasien : …………………………………………….
7) Status perkawinan : ………………………………………………..
2. Riwayat Kesehatan
a. Kesehatan Pasien
1) Keluhan Utama saat Pengkajian
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2) Riwayat Kesehatan Pasien
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b. Pemeriksaan kehamilan saat ini
1) G.....P.....A....
2) HPHT : ..........................................................................
3) HPL : ..........................................................................
4) Usia Kehamilan : .........................................................................
5) Keluhan yang muncul selama kehamilan:
a) Trimester I : ..........................................................................
b) Trimester II : ..........................................................................
c) Trimester III : .........................................................................
c. Riwayat Obstetri
Anak Jenis Tahun Cara Penolong BB Komplikasi Keada
ke Kelamin lahir Lahir persalinan Lahir selama an saat
persalinan ini
 d. Riwayat Ginekologi
1) Menarche : ................................................................................. .
2) Siklus menstruasi : ..........................................................................
3) Karakteristik menstruasi: ........................................................................
4) Keluhan menstruasi : ..........................................................................
5) Penyakit ginekologi yang pernah diderita: ............................................
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e. Riwayat kontrasepsi
Tahun Jenis Tenaga Kontrol Keluhan
pemakaian kontrasepsi kesehatan kontrasepsi
pemasang
kontrasepsi

f. Riwayat Kesehatan Keluarga

1) Genogram

Keterangan Gambar :
 2) Riwayat Kesehatan Keluarga
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3. Kesehatan Fungsional
a. Aspek Fisik – Biologis
1) Nutrisi
a) Pola makan frekuensi, jenis, dan jumlah
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b) Perubahan pola selama hamil
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c) Alergi makanan
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d) Minum jumlah dan jenis
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e) Keluhan yang berhubungan dengan nutrisi
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2) Pola Eliminasi
a) BAK selama hamil
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b) BAB selama hamil
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c) Aktifitas dan latihan
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3) Istirahat dan tidur
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4) Pola seksualitas
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b. Aspek Psiko-Sosial-Spiritual
1) Pemeliharaan dan pengetahuan terhadap kesehatan
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2) Pola hubungan
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3) Koping atau toleransi stres
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4) Kognitif dan persepsi tentang kehamilan
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5) Efek kehamilan terhadap body image

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6) Motivasi terhadap kehamilan
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4. Pemeriksaan Fisik
a. Keadaan Umum
1) Kesadaran :…………………………………………………………
2) Status Gizi :TB = cm
BB = Kg
3) Tanda Vital : TD = mmHg Nadi = x/mnt
Suhu = °C RR = x/mnt
b. Pemeriksaan Secara Sistematik (Cephalo – Caudal)
1) Kulit
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2) Kepala
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3) Leher
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4) Tengkuk
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5) Dada
a) Inspeksi
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b) Palpasi
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c) Perkusi
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d) Auskultasi
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6) Payudara
a) Inspeksi
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b) Palpasi
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7) Punggung
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8) Abdomen
a) Inspeksi
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b) Auskultasi
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c) Palpasi
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9) Panggul
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10) Anus dan Rectum

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11) Genetalia
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12) Ekstremitas
a) Atas

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b) Bawah
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 5. Pemeriksaan Penunjang
a. Pemeriksaan Patologi Klinik
Tabel 3.4 Pemeriksaan laboratorium Ny............... di Ruang ................. di
Rumah Sakit..................... Yogyakarta Tanggal...................

Tanggal Jenis Hasil (satuan) Normal

Pemeriksaan Pemeriksaan
 Tanggal Jenis Hasil (satuan) Normal
Pemeriksaan Pemeriksaan

(Sumber Data Sekunder : RM Pasien )

Tabel 3.5 Hasil Pemeriksaan Radiologi
Pasien........ di Ruang .......... Rumah Sakit................. Tanggal...

Hari/ Jenis Pemeriksaan Kesan/Interpretasi

Tanggal
 (Sumber Data Sekunder : RM Pasien)

6. Terapi
Tabel 3.6 Pemberian Terapi Pasien...... di Ruang ........ Rumah Sakit.............
Tanggal .........

Hari / Obat Dosis dan Satuan Rute

Tanggal
 (Sumber Data Sekunder : RM Pasien)
7. ANALISA DATA
Tabel 3.7 Analisa Data
Pasien ...... di Ruang ...... Rumah Sakit.................... Tanggal.......

NO ANALISA DATA PENYEBAB MASALAH

 B. DIAGNOSA KEPERAWATAN

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 C. PERENCANAAN KEPERAWATAN

Nama Pasien / NO CM : ………………………………../……………………………… Ruang :..................................................................

Hari/ PERENCANAAN
Tgl/ Jam DIAGNOSA KEPERAWATAN
PELAKSANAAN EVALUASI
TUJUAN RENCANA TINDAKAN
 D. CATATAN PERKEMBANGAN

Nama Pasien/No. C.M :…………………/……..Ruang :…………………………….

Diagnosa Keperawatan : ..................................................................................................

HR/TGL/ EVALUASI
PELAKSANAAN
JAM (S O A P)